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I request that payment of authorized Medicare/Insurance benefits be made either to me or on my behalf to Miami Lakes Eye Care Center for any services furnished me by that physician or supplier. I authorize any holder of medical information to release to the Health Care Financing Administration and its agents any information needed to determine these benefits payable to related services. I understand my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If other health insurance coverage is indicated on Item 9 of the HCFA-1500 claim form or elsewhere on other approved electronically submitted claims, my signature authorizes releasing of the information to the insurer or agency shown. In Medicare-assigned cases, the physician or supplier agrees to accept the charge determination of the Medicare carrier as the full charge, and the patient is responsible only for the deductible, coinsurance, and non-covered services. Coinsurance and deductible are based upon the charge determination of the Medicare carrier. It is understood that the undersigned and/or the patient are primarily responsible for the payment of my bill.
I authorize Miami Lakes Eye Care Center, to release or discuss information related to my medical condition (including information related to my treatment plan, medication information and/or billing information) to the following named person(s)*
* Please be advised that any person not referred to on this list will not be given any information related to your care, including billing information. You may change, restrict or expand this listing at any time. * You are not required to list any name if you do not so choose.
Please list any additional phone numbers where you would like us to contact you for: * Reminder notices * Changes on scheduled appointments
Form of payment for today’s Services
I understand there may be a separate Refraction Fee of $33.00 or Contact lens Fee for first time Fit of $70.00 and $35.00 for re-fit, for which my insurance may not cover.
I understand there is an added fee for returned checks and collections accounts.